Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 55 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
4G
1H
0I
Potential for more than minimal harm
35D
12E
2F
Potential for minimal harm
0A
0B
0C
April 17, 2026Complaint inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision and develop a plan to maintain the resident's safety during a scheduled room maintenance activity that required removal from his/her room. Resident #1 had known aggressive behaviors and preferred to remain in his/her room; however, when displaced into a common area without an established supervision plan, the resident was not adequately monitored and entered another resident's room, resulting in a resident-to-resident altercation with injury.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Residents #1) reviewed for abuse, the facility failed to ensure the Resident Care Plan (RCP) was updated following a room change for a severity cognitively impaired resident with adjustment disorder, when the resident was moved from a room on the secured unit to a room on the non-secured unit after a resident-to-resident physical altercation.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Residents #1) reviewed for abuse, the facility failed to ensure a resident involved in a physical altercation received a harm clearance prior to returning to the facility.
February 11, 2026Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #10) reviewed for accidents, the facility failed to ensure staff opened an access door to a resident unit in a safe manner to ensure a resident was not hit by the door. The failure resulted in a resident fall with injury.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #6) reviewed for therapy, the facility failed to ensure the clinical record was complete and accurate to include orthopedic consults, post wrist surgery documentation and related therapy notes as part of the medical record.
December 19, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1), reviewed for accidents, the facility failed to adequately supervise a resident with a known history of wandering who ambulated independently, during a period with a higher than usual volume of visitors, to ensure the resident remained on the secured memory care unit when visitors were entering and exiting. Subsequently, the resident exited the secured memory care unit, ambulated through two facility hallways, exited the main facility entrance without staff knowledge, and was located by police 0.4 miles away from the facility. This failure resulted in the finding of Immediate Jeopardy.
November 18, 2025Complaint inspection · 2 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of falls, the facility failed to complete a fall risk assessment following the fall in accordance with facility policy.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observations, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff assistance with personal hygiene, the facility failed to ensure infection control practices were implemented and dirty linen and a soiled incontinent brief were not left on top of the resident's table in the room.
November 12, 2025Standard inspection, Complaint inspection · 14 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the residents had a safe, clean, comfortable environment.
- E
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on observations, review of clinical records, review of the facility assessment and interviews for four sampled residents residing on a secured nursing unit (Residents #32, #69, #161 and #173) and reviewed for involuntary seclusion, the facility failed to assess, care plan, demonstrate that the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record reviews and interviews for 6 of 6 sampled residents (Residents #31, #45, #49, #56, #62, and #64) reviewed for resident assessment, the facility failed to ensure quarterly MDS assessments were completed timely.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility documentation, review of facility policy, and interviews during a review of the Infection Control Program, the facility failed to ensure environmental rounds were conducted/completed monthly, the facility failed to ensure infection surveillance data collection reports and analysis of infection trends within the facility were completed monthly, and failed to follow the policy and procedural measures developed by the facility to prevent the growth of Legionella and other water borne pathogens in the building water system.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of facility documentation, review of facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure the antibiotic surveillance tracking report of antibiotic usage and outcome was collected and documented for analysis.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, review of the clinical records, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #151) observed with medications left unattended at the bedside, and (Resident #178) on controlled anti-anxiety medication, the facility failed to ensure that medications were administered and failed to ensure documentation entered on the medication administration record was in accordance with professional standards of practice.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for three sampled residents (Residents #1, #66 and #123) reviewed for pressure ulcer, the facility failed to ensure skin checks were being completed prior to the identification of a pressure ulcer and an assessment of a skin issue following identification as well as a provider order implemented and failed to ensure the low air loss mattress was set according to the physician's orders
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, review of facility documentation, and interviews for two of four sampled residents (Resident #111 & 133) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during resident transport to prevent an accident and failed to ensure adequate supervision was provided to prevent resident from smoking in the facility ground after repeated non-compliance with non-smoking policy.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility documentation, review of facility policy, and staff interviews for two of three nurse aides (NA #4 and NA #5), the facility failed to complete an annual performance evaluation.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs was in place to sufficiently enable an accurate reconciliation of all controlled medications.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, review of facility policy/procedures and interviews, the facility failed to ensure expired or discontinued medications were removed from the medication cart according to facility policy.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident#32, and Resident #173) reviewed for food, the facility failed to ensure the food tray ticket were accurate and fruit was available to the resident.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #59) reviewed for immunizations, the facility failed to offer and/or assess for pneumococcal immunizations to the resident.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on review of the clinical records, review of facility documentation, facility policy/procedures, and interviews for 1 of 5 residents (Resident #59) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination were offered and/or assessed to resident.
August 28, 2025Complaint inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of the clinical record, facility documentation, and facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure the provider was notified timely of a delay in obtaining STAT (immediate) laboratory work in accordance with physician orders, and failed to ensure the physician/APRN was notified timely of critical lab results.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure laboratory work was obtained timely in accordance with physician orders, and failed to act on critical lab results timely.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and interviews for two of three residents (Resident # 2 and Resident #3) reviewed for abuse, the facility failed to ensure adequate supervision for residents with known wandering behaviors to prevent a resident-to-resident interaction.
April 7, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure staff reported an allegation of abuse in a timely manner.
October 31, 2024Complaint inspection · 6 citations
- H
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and staff interviews the facility failed to ensure residents were free from abuse for three (3) of five (5) residents (Resident ID # 2, #3 and #7). The facility failed to ensure interventions were in place to address verbal altercations which occurred prior to a physical altercation between Resident #1 and Resident #2, and for Resident #3 and #7 the facility failed to ensure the residents were free from physical and psychosocial abuse.
- F
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on clinical record reviews, facility policy and interviews for seven (7) of fifteen (15) residents (Residents #1, #2, #3, #4, #5, #6, and #7) reviewed for physician visits, the facility failed to ensure physician visits were conducted in accordance with state agency requirements.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who was reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a dignified and respectful manner.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of clinical records, interview, and review of facility documentation for two (2) of six (6) residents reviewed for the plan of care for Resident #4, the facility failed ensure a velcro stop sign was in place in accordance with the plan of care, and for Resident #6 reviewed for falls, the facility failed to follow a care plan intervention.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, interview, and review of facility policy for one (2) of three (3) residents (Resident #1 and Resident #6) reviewed for medication and treatment administration, the facility failed to administer a psychiatric medication to a resident with a schizophrenia and failed to provide wound care to a patient with a Stage III pressure ulcer.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records, interviews and review of facility documentation for one (1) of three (3) residents, (Resident #6) reviewed for activities of daily living, the facility failed to document activities of daily living each shift.
August 6, 2024Complaint inspection · 1 citation
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for five (5) of five (5) sampled residents (Residents #4, #5, #6, #7 and #8) who were recently admitted to the facility, the facility failed to provide the residents or their representatives a summary of a baseline or comprehensive care plan within forty-eight (48) hours of admission and conduct a care plan meeting.
July 15, 2024Complaint inspection · 3 citations
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) reviewed for resident rights, the facility failed to manage the resident's personal funds accordingly.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for care and services, the facility failed to ensure a follow-up consultant appointment was scheduled timely.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents, (Resident #2) reviewed for care and services , the facility failed to ensure that a residents room was kept in a sanitary condition.
April 17, 2024Complaint inspection · 2 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for one sampled resident (Resident #1) who refused medications at times, the facility failed to ensure pre-poured, unlabeled medications for the resident were not left in a medication cup in an unlocked medication cart.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, facility policy and interviews for one (1) of three (3) medication rooms located at the nurse's station, the facility failed to ensure the medication room door on the dementia unit was closed and locked and failed to ensure the two (2) medication carts in the medication room were locked while the door was propped open.
December 12, 2023Standard inspection · 14 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy and interviews, for one of two sampled residents (Resident #375) reviewed for pain management, the facility failed to administer pain medication when the resident made a request to be medicated.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, the facility failed to provide a homelike environment.
- E
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
Inspectors wroteBased on review of the grievances, review of facility policy, and interviews, the facility failed to ensure that residents received a written copy of the summary/resolution and failed to identify that the resolution was discussed with the residents.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #59) with a therapeutic diet, the facility failed to ensure that an ordered assessment for speech therapy was completed.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility documentation, review of facility policy and interviews, the facility failed to ensure accurate reconciliation of controlled medication in the facility's emergency automated dispensing supply unit.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, review of facility documentation, review of facility policy and interviews, the facility failed to ensure sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, clinical record review, review of facility documentation, and interviews, for two of nine sampled residents (Resident #19, and Resident #116), reviewed for dining, the facility failed to provide menu choices.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, and interviews, the facility failed to maintain a clean and sanitary kitchen environment.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review, facility policy review, and interviews for two sampled residents (Resident #16 and #375) reviewed for advance directives, the facility failed to obtain the most recent advance directive from the legal representative when the resident's code status changed and failed to ensure there was a physician's order indicating the resident's wishes related to cardiopulmonary code status, hospitalization, artificial nutrition, and intravenous fluids.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on clinical record review, facility policy review, and interviews for one of two sampled residents (Resident #85) admitted to the facility in the past three months, the facility failed to develop a baseline care plan to direct the resident's care needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, and interviews for one of two sampled residents (Resident #53) reviewed for pressure ulcers, the facility failed to ensure the Registered Nurse (RN) assessed a newly admitted resident with pressure wounds in accordance with professional standards of practice.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, review of the clinical record, review of facility policy, and interviews for Resident one of five sampled residents (Resident #92) reviewed for unnecessary medications and received psychotropic medication, the facility failed to complete an Abnormal Involuntary Motion Scale (AIMS) assessment every six months.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, review of facility policy and interviews for one of two medication storage rooms and one of three medication carts, the facility failed to remove expired medications from medication circulation.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, review of facility policy and interviews for three sampled residents (Residents #92, #97, and #116) the facility failed to ensure medical records were readily accessible and complete.
September 9, 2021Standard inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, observations, facility documentation review, facility policy review and interviews for one of two residents (Resident #90) reviewed for accidents, the facility failed to ensure staff supported the resident's head, neck, and back in accordance with facility policy during a mechanical lift (Hoyer) transfer to prevent a fall with injury.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, facility documentation review and interviews, the facility failed to ensure food was stored and prepared in accordance with standards for food service safety.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #222) reviewed for catheter use, the facility failed to ensure catheter was changed in accordance with the physician's order.
Fire safety inspections
23 fire safety citations on file: 17 on November 12, 2025, 2 on December 12, 2023, 4 on September 9, 2021.
Every fire safety citation23 citations
- D
Establish staff and initial training requirements.
E 37 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · November 12, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 12, 2025 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 12, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 12, 2023 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · September 9, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 9, 2021 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · September 9, 2021 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · September 9, 2021 · Corrected (the home has a date of correction)